The use of plasmapheresis for rapid hormonal control in severe hyperthyroidism caused by a partial molar pregnancy

Thyroid storm in pregnancy: a review

BACKGROUND

Thyroid storm is a state of circulating thyroid hormone excess leading to multiorgan dysfunction and systemic decompensation. It typically occurs in the setting of poorly controlled hyperthyroidism and a precipitating illness or event. Management of thyroid storm in pregnancy poses unique diagnostic and therapeutic challenges.

MAIN BODY

Thyroid storm is a clinical diagnosis characterized by hyperpyrexia, tachyarrhythmias, congestive heart failure, gastrointestinal and neuropsychiatric disturbances. However, diagnostic scoring systems have not been validated in pregnancy. Treatment involves specialist consultation, supportive care, and pharmacological options such as anti-thyroid medications, beta blockers, iodine solutions, glucocorticoids, and cholestyramine. These must be adapted and modified in pregnancy to prevent fetal and maternal complications.

CONCLUSION

There is a critical need to recognize thyroid storm during pregnancy and initiate proper medical interventions promptly.

Therapeutic plasma exchange for Graves' disease in pregnancy

Graves' disease in pregnancy may be associated with maternal, fetal and neonatal complications, which are proportionate to the severity of hyperthyroidism. Optimal management is detailed preconception counselling, achievement of an euthyroid state prior to conception, and close monitoring of thyroid function and thyroid-stimulating antibodies together with judicious use of anti-thyroid medications during pregnancy. A case of Graves' disease in pregnancy, complicated by pancytopenia, with a deterioration in thyroid function following cessation of thionamide therapy is described here. Therapeutic plasma exchange was subsequently used to achieve rapid control prior to thyroidectomy. Therapeutic plasma exchange is an effective treatment for hyperthyroidism where thionamides are ineffective or contraindicated, as a bridge to definitive management.

Efficacy of preoperative therapeutic plasma exchange in patients with hyperthyroidism and factors affecting the number of sessions

PURPOSE

Achieving preoperative euthyroidism in patients with hyperthyroidism for whom antithyroid drugs (ATDs) cannot be used for treatment is a serious clinical problem. We aimed to evaluate the effectiveness of therapeutic plasma exchange (TPE) in hyperthyroid patients scheduled for surgery and predictive factors for a high number of TPE sessions.

METHODS

We retrospectively analyzed the data of 21 patients with hyperthyroidism who were treated with TPE for preoperative euthyroidism in our institution. Pre- and post-TPE thyroid function tests were compared to assess efficacy. Binary logistic regression analysis was applied to determine predictors of patients requiring a high number of TPE sessions.

RESULTS

All patients (20 patients with Graves' disease and 1 patient with toxic multinodular goiter; 12 women and 9 men; mean age 35.71 ± 12.38 years) had severe hyperthyroidism before TPE. The changes before and after TPE in fT3, fT4, and TSH levels were statistically significant (p < 0.001, p < 0.001, p = 0.002, respectively). The median number of TPE sessions was 8 (range: 1-24). Levels of fT3 before TPE were significantly higher in patients for whom higher numbers of TPE sessions were required (≥8) (OR: 1.427, 95% CI: 1.038-1.961, p = 0.028). Receiver operating characteristic curve analysis revealed an optimum cut-off value of 12.8 pg/ml for fT3 before TPE (91% sensitivity, 80% specificity, area under the curve: 0.927).

CONCLUSION

TPE should be considered as an effective alternative treatment option that can be used to rapidly achieve euthyroidism before surgery when ATDs cannot be used. Pre-TPE fT3 levels of >12.8 pg/ml may be an independent factor predicting the need for higher numbers of TPE sessions (≥8).

Preoperative plasmapheresis in patients with Graves' disease intolerant to antithyroid drugs

Antithyroid drugs (ATDs) are the mainstay of treatment for Graves' disease with possible detrimental adverse effects. Surgery or radioactive iodine (RAI) ablation is the second choice among the treatment options in cases of non-remission. Normalization of serum thyroid hormone levels as much as possible is required before surgery or RAI to prevent thyrotoxic crisis in patients with uncontrolled Graves' disease. In recent decades, therapeutic plasma exchange (TPE) has been used in the treatment of thyroid storm, drug-induced hepatotoxicity and agranulocytosis, or patients with hyperthyroidism scheduled for emergency surgery. TPE is an effective method to reduce serum FT3, FT4, and TRAB levels in severe hyperthyroid conditions. Although TPE-related complications are rare, the risk of bleeding needs to be taken into consideration in patients who were scheduled for surgery within 24 h after TPE. In terms of reducing intraoperative bleeding, patients can be referred to surgery 24-48 h after TPE, or fresh frozen plasma transfusion can be the preferred treatment for emergency cases.

Hyperthyroidism in gestational trophoblastic disease - a literature review

OBJECTIVE

Gestational trophoblastic disease (GTD) is a group of pregnancy-related disorders that arise from abnormal proliferation of placental trophoblast. Some patients with GTD develop hyperthyroidism, a rare but potentially life-threatening complication requiring early detection and management. Existing literature on hyperthyroidism in GTD is scant. This review aims to analyse the epidemiology, pathophysiology and management of this phenomenon.

METHODS

A comprehensive search of MEDLINE, EMBASE and Cochrane Library was performed to obtain articles that explored hyperthyroidism in GTD. A total of 405 articles were screened and 228 articles were considered for full-text review. We selected articles that explored epidemiology, pathophysiology and outcomes/management of hyperthyroidism in GTD.

RESULTS

The pathophysiology of hyperthyroidism in GTD is well-investigated. Placental trophoblastic tissue secretes excessive hCG, which is structurally similar to thyroid stimulating hormone and also has enhanced thyrotropic activity compared to normal hCG. The incidence and prevalence of hyperthyroidism in GTD varies worldwide, with lower rates associated with high uptake of early antenatal screening and early GTD detection. No clear risk factors for hyperthyroidism in GTD were identified. While hyperthyroidism can be definitively managed with surgical evacuation of the uterus, severe complications associated with hyperthyroidism in GTD have been reported, including thyroid storm-induced multi-organ failure, ARDS, and pulmonary hypertension.

CONCLUSION

Early detection of GTD is critical to prevent development of hyperthyroidism and its associated complications. Hyperthyroidism should be recognised as an important perioperative consideration for women undergoing surgery for GTD, and requires appropriate management. Future studies should explore risk factors for hyperthyroidism in GTD, which may facilitate earlier identification of high-risk women.

The role of therapeutic plasmapheresis in patients with hyperthyroidism

BACKGROUND

Hyperthyroidism is characterized by excess hormone secretion from the thyroid gland. Anti-thyroid drugs (ATDs), surgery, and radioactive iodine can be used in treatment. Plasmapheresis is a rapid and effective treatment option in cases where rapid euthyroidism is needed to be obtained due to complications of thyrotoxicosis and major adverse effects of ATDs.

MATERIAL AND METHOD

We present patients receiving plasmapheresis to provide immediate euthyroidism due to severe hyperthyroidism, adverse effects of ATDs, or non-thyroid surgery from January 2012 to December 2016.

RESULTS

This study included 18 patients. The etiology of hyperthyroidism was TDG in seven patients, TDMNG in two, TA in two, TMNG in four, and one patient had AIT. Plasmapheresis was performed to achieve euthyroidism before surgery in two patients. The mean plasmapheresis session was 5.35. The mean number of sessions needed for patients with TDG and TDMNG was 4, whereas it was 6.5 for patients with TA and TMNG (p = 0.07). The decrease of mean free thyroxine and free triiodothyronine were 57 % and 73 %, respectively (p < 0.001). After plasmapheresis, total thyroidectomy was performed in 14 patients. Euthyroidism was achieved with RAI in one patient and with medical therapy in three patients.

CONCLUSIONS

Plasmapheresis therapy is a reliable and effective treatment option for patients who cannot use ATDs because of their adverse events and those with hyperthyroidism that does not resolve with these drugs, or to achieve euthyroidism before total thyroidectomy, RAI or non-thyroid emergency surgery. However, it cannot be used widely because it is expensive and invasive.

Weathering the storm: A case of thyroid storm refractory to conventional treatment benefiting from therapeutic plasma exchange

Thyroid storm is a severe manifestation of thyrotoxicosis characterized by systemic organ dysfunction secondary to a hypermetabolic state. Although antithyroid drugs, steroids, beta-blockers, antipyretics, and cholestyramine are the standard of care, some patients inadequately respond to these conventional therapies. Therapeutic plasma exchange has been previously utilized as a treatment modality in patients with a poor response to routine therapies or with contraindications to them. Herein, we report our experience with the management of a case of thyroid storm refractory to conventional treatment but responsive to therapeutic plasma exchange.

Severe Hyperthyroidism Complicated by Agranulocytosis Treated with Therapeutic Plasma Exchange: Case Report and Review of the Literature

AIM

To present a case of Graves' disease complicated by methimazole induced agranulocytosis treated with therapeutic plasma exchange (TPE) and review of the literature.

CASE PRESENTATION

A 21-year-old patient with a history of Graves' disease presented to the endocrine clinic. His history was significant for heat intolerance, weight loss, and tremors. Upon examination he had tachycardia, smooth goiter, thyroid bruit, and hyperactive reflexes. He was started on methimazole and metoprolol and thyroidectomy was to be done once his thyroid function tests normalized. On follow-up, the patient symptoms persisted. Complete blood count done showed a white blood cell count of 2100 (4000-11,000 cells/cu mm) with a neutrophil count of 400 cells/cu mm, consistent with neutropenia. He was admitted to the hospital and underwent 3 cycles of TPE and was also given filgrastim. He improved clinically and his thyroxine (T4) levels also came down. Thyroidectomy was done. He was discharged on levothyroxine for postsurgical hypothyroidism.

CONCLUSION

Plasmapheresis may be useful in the treatment of hyperthyroidism. It works by removing protein bound hormones and also possibly inflammatory cytokines. Further studies are needed to clarify the role of various modalities of TPE in the treatment of hyperthyroidism.

Transient Thyrotoxicosis in Molar Pregnancy

Molar pregnancy is one of the components of a broader spectrum of diseases known as Gestational Trophoblastic Disease (GTD), presenting with amenorrhoea and irregular bleeding which may be rarely associated with passage of vesicles per vagina. However, it can rarely be associated with hyperthyroidism, which may be associated with clinical features of hyperthyroidism. The following is a report of a 20-year-old woman who presented with amenorrhea followed by irregular bleeding per vagina, thyromegaly and abnormal levels of thyroid hormones. Transvaginal ultrasound revealed features consistent with molar pregnancy. A suction evacuation was done following which serum levels of β-hCG reduced and the levels of thyroid hormones also reduced. On follow up, six weeks later, β-hCG and thyroid hormones were within normal limits. The case and relevant literature are presented here.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.

Therapeutic apheresis in pregnancy: General considerations and current practice

It is widely known that pregnancy does not represent a contraindication to therapeutic apheresis (TA) techniques. In fact, since the first experiences of TA in pregnancy for the prevention of hemolytic disease of the newborn, several diseases are at present treated with TA, mainly within 6 clinical categories: (a) TA is a priority and has no alternative equally effective treatment (e.g., thrombotic thrombocytopenic purpura); (b) TA is a priority but there are alternative therapies not contraindicated in pregnancy (e.g., myasthenia gravis); (c) TA is an effective tool of saving/avoiding drugs contraindicated in pregnancy (e.g., systemic lupus erythematosus); (d) TA is a treatment of specific conditions/complications of pregnancy with maternal and/or fetal risk (e.g., antiphospholipid syndrome); (e) TA is a treatment of specific conditions of pregnancy with exclusive fetal risk (e.g., hemolytic disease of the newborn); (f) TA is a treatment of disease which is strongly indicated and can exceptionally occur during pregnancy (e.g., Goodpasture's syndrome). When dealing with TA pregnant patients, some technical aspects due to the physiological changes of gestation have to be carefully considered, in particular the increase of the circulating blood volume. Moreover a multidisciplinary medical team, including an obstetrician, a clinical consultant, specialist in TA and in transfusion medicine, and a neonatologist stand as a basic requirement for the proper management of some clinical conditions that may be characterized by high maternal and fetal risk.

Effectiveness of preoperative plasmapheresis in a pregnancy complicated by hyperthyroidism and anti-thyroid drug-associated angioedema

Hyperthyroidism is not a rare entity in pregnancy and 85% of these cases attributed to Graves' disease (GD). There is no therapeutic modality for GD considered as totally safe in pregnancy. Fetal and neonatal risks of maternal hyperthyroid disease are related to the hyperthyroidism itself and/or to the medical treatment of the disease. There are no data supporting an association between congenital anomalies in the fetus and propylthiouracil (PTU). Hepatotoxicity, cytopenias--especially agranulocytosis and quite rarely, angioedema, may be seen as side effects of PTU. In this case report, we examine an instance of Graves' hyperthyroidism diagnosed during pregnancy. In this case, a serious side effect during anti-thyroid drug usage was encountered, eventually resulting in surgery in the second trimester. This intervention was assisted by the use of plasmapheresis to obtain rapid normalization of serum thyroid hormone levels.

Role of plasma exchange in the thyroid storm

Inadequately treated thyroid storm can lead to death. Therapeutic plasma exchange (TPE) is a suggested treatment when conventional treatments fail, but its indication is not well codified. We report our experience through three explicit cases. Three elderly patients were admitted to our hospital for cardiac or neurologic symptoms due to thyroid storm. After initiation of conventional therapy, TPE was performed with clinical and biological improvement. The speed of symptom resolution varies depending on the severity. This technique must be carried out by experienced medical staff as many complications can occur; nevertheless, in our patients with severe comorbidities, no complications occurred. The action of TPE mainly results from plasma removal of cytokines, putative antibodies, and thyroid hormones and their bound proteins. TPE has a transitory effect and thus should be associated with other thyroid blockers. When there are threatening symptoms, TPE should be done early, without waiting for the efficiency of conventional treatment, since it is the fastest method known for the improvement of the clinical condition. We also suggest starting TPE in case of neurologic symptoms because of very slow and incomplete regression. The Burch and Wartofsky score seems to be a helpful tool in establishing the diagnosis of thyroid storm and for deciding on when to initiate TPE.

Thyrotoxic crisis associated with gestational trophoblastic disease

BACKGROUND AND OBJECTIVES

Human chorionic gonadotropin (HCG) and thyrotrophic hormone (TSH) have analogies in their structures, as well as in their receptors. The high levels of HCG seen in gestational trophoblastic diseases may induce secondary hyperthyroidism. The objective of this report was to present a case in which the administration of iodinated contrast triggered a thyrotoxic crisis.

CASE REPORT

Patient with complete hydatidiform mole who was admitted to the operating room with severe vaginal bleeding after a tomographic exam with iodinated contrast. During anesthetic induction, the patient presented symptoms compatible with thyrotoxic crisis.

CONCLUSIONS

The incidence of severe presentations associated with gestational trophoblastic disease tends to decrease with early diagnosis. Still, the anesthesiologist should be aware of the possibility of those patients developing thyrotoxic crisis.

Guidelines on the use of therapeutic apheresis in clinical practice--evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis

The American Society for Apheresis (ASFA) Apheresis Applications Committee is charged with a review and categorization of indications for therapeutic apheresis. Beginning with the 2007 ASFA Special Issue (fourth edition), the subcommittee has incorporated systematic review and evidence-based approach in the grading and categorization of indications. This Fifth ASFA Special Issue has further improved the process of using evidence-based medicine in the recommendations by refining the category definitions and by adding a grade of recommendation based on widely accepted GRADE system. The concept of a fact sheet was introduced in the Fourth edition and is only slightly modified in this current edition. The fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis. The article consists of 59 fact sheets devoted to each disease entity currently categorized by the ASFA as category I through III. Category IV indications are also listed.

Molar pregnancy-induced thyroid storm

BACKGROUND

Molar pregnancy is a rare form of pregnancy, affecting approximately 1 in 1000 pregnancies in the United States. Hyperthyroidism is a rare complication of molar pregnancy; thyroid storm occurs even less frequently.

OBJECTIVES

To discuss a rare cause of thyroid storm in a woman of reproductive age.

CASE REPORT

A 17-year-old girl presented to a community hospital's Emergency Department (ED) after experiencing 1 week of palpitations and tachycardia. The tachycardia partially responded to administration of calcium channel blockers and beta-blockers. The patient was transferred to a tertiary care center for further evaluation. At the tertiary center, pregnancy was confirmed, thyroid storm was diagnosed, and ultrasound examination yielded a snowstorm image, indicating a molar pregnancy. The patient was admitted to the intensive care unit for management. Dilatation and curettage resolved her symptoms, and after a 9-day hospital stay, she was discharged home on atenolol therapy.

CONCLUSIONS

Thyroid storm induced by gestational trophoblastic disease should be considered in any woman of childbearing age who presents with symptoms suggestive of hyperthyroidism.